Provider Demographics
NPI:1164938684
Name:STONEHAM, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:STONEHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 CEDARBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4932
Mailing Address - Country:US
Mailing Address - Phone:732-363-3335
Mailing Address - Fax:
Practice Address - Street 1:CORNERSTONE AT TOMS RIVER APT 219
Practice Address - Street 2:2121 MASSACHUSETTS AVE. APT 219
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-1564
Practice Address - Country:US
Practice Address - Phone:732-363-3335
Practice Address - Fax:732-363-3335
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0463027Medicaid